C5神经根麻痹

1、C5 nerve root palsy following decompression of the cervical spineZhu xi The Orthopaedics of General Hospital of NMU J. Z. Guzman, BS, From Icahn School of Medicine at Mount Sinai, New York,United States Bone Joint J 2014;96-B:9505.Preface vC5 nerve root palsy is a rare and potentially debilitating c

2、omplication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication.v颈颈 5 神经根麻痹较为少见，是颈椎术后可能出现神经根麻痹较为少见，是颈椎术后可能出现的较为严重的并发症，然而，到目前为止，尚没的较为严重的并发症，然而，到目前为止，尚没有相关指南帮助外科医师预防和治疗有相关指南帮助外科医师预防和治疗 C5 神经根神经根麻痹。麻痹。Prefacev We carried out a sy

3、stematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery.v 为此，作者对文献进行了系统回顾和总结，以明确该并发为此，作者对文献进行了系统

4、回顾和总结，以明确该并发症发生的原因，探讨其预防和治疗的方法。检索症发生的原因，探讨其预防和治疗的方法。检索PubMed，EMBASE和和MEDLINE选出选出60篇文章，其篇文章，其中大部分将中大部分将C5麻痹作为手术并发症。麻痹作为手术并发症。PrefacevAlthough many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely.v尽管存在许

5、多可能的致病因素，但多数作者认为尽管存在许多可能的致病因素，但多数作者认为颈椎术后脊髓向后漂移、进而引起神经根牵拉是颈椎术后脊髓向后漂移、进而引起神经根牵拉是最可能的因素。最可能的因素。MATERIALS AND METHODSv We performed a systematic search with PubMed 、Embase、Medline of the years between 2000 and 2013 using the terms “C5 palsy” and “cervical spine”.The criteria for inclusion were the rele

6、vance of the articles to the aetiology, outcome, prevention and treatment of a post-operative C5 nerve root palsy.The level of evidence of each article was determined using the methods of the Oxford Centre for Evidence Based Medicine.v 作者以作者以“C5麻痹麻痹”和和“颈椎颈椎”作为关键词对作为关键词对2000-2013年期间在年期间在PubMed、EMBASE

7、和和MEDLINE上的文献进行了系统检索。纳入上的文献进行了系统检索。纳入标准为：文章需要与术后标准为：文章需要与术后C5神经根麻痹的病因学、结果、预防及治神经根麻痹的病因学、结果、预防及治疗相关。每一篇论文的证据等级均采用牛津循证医学中心的方法进行疗相关。每一篇论文的证据等级均采用牛津循证医学中心的方法进行确定。确定。Resultsv Anterior Decompression：Analysis of the literature revealed an incidence of C5 root palsy after anterior decompression of between 0

8、% and 26.4%.v Two-level corpectomy with autograft fusion and plate fixation had the highest incidence at 26.4%.v 前路减压：颈前路减压术后前路减压：颈前路减压术后 C5 神经根麻痹的发生率为神经根麻痹的发生率为 0%-26.4%。v 两节段椎体次全切植骨融合固定术后的发生率最高，为两节段椎体次全切植骨融合固定术后的发生率最高，为26.4%。ResultsResultsv Shibuya et and Wada et both reported lower incidences at

9、8.8% and 4%, respectively, in their studies of subtotal corpectomy.v Anterior hybrid decompression,in which a single-level corpectomy and singlelevel discectomy is performed, had an incidence of 1.9%.v Using a similar hybrid technique, Odate et reported an incidence of 3%.v Shibuya团队和团队和Wada团队报道颈椎次全

10、切术后团队报道颈椎次全切术后C5神经根麻痹的发神经根麻痹的发生率分别为生率分别为8.8%及及4%。v 前路混合式减压（前路混合式减压（单节段单节段ACCF和和ACDF）术后的发生率为）术后的发生率为1.9%。v 同样采用混合式技术，同样采用混合式技术，Odate等报道的发生率则为等报道的发生率则为3%。Resultsv Due to some studies which evaluated several procedures, we considered each evaluation separately. Overall, 20 evaluations of anterior decom

11、pression resulted in an incidence of 7.7%.v 由于一些研究是针对手术方式进行分析的，因此我们对不由于一些研究是针对手术方式进行分析的，因此我们对不同术式的并发症分别进行了评估。结果表明，有关前路减同术式的并发症分别进行了评估。结果表明，有关前路减压的压的20项研究的发生率为项研究的发生率为7.7%。Resultsv Posterior Decompression：The incidence of C5 nerve root palsy after posterior decompression was between 0% and 50%.v Lami

12、noplasty of various types resultedin an incidence of up to 17%.v Cervical expansive laminoplasty resulted in a 4%.v While a concurrent bilateral foraminotomy decreased the incidence to 0.6%.v 后路减压：颈后路减压术后后路减压：颈后路减压术后C5神经根麻痹的发生率在神经根麻痹的发生率在 0%-50% 之间之间。v 各种类型的椎板成形术的发生率最高可达各种类型的椎板成形术的发生率最高可达17%。v 颈椎管扩大

13、成形术后的发生率为颈椎管扩大成形术后的发生率为4%。v 而同时行椎间孔切开术后而同时行椎间孔切开术后C5神经根麻痹的发生率则降低到神经根麻痹的发生率则降低到 0.6%。ResultsResultsv A retrospective review by Katsumi which considered open door laminoplasty with C4/C5 foraminotomy, gave a 1.4% incidence of C5 root palsy which further supports the use of prophylactic foraminotomy in

14、 the prevention of a C5 palsy.Overall,v articles which addressed posterior decompression yielded a mean incidence of 7.8%.v Katsumi 等进行了一项回顾性研究，认为椎管成形术同时行等进行了一项回顾性研究，认为椎管成形术同时行C4/C5 椎间孔切开术患者术后椎间孔切开术患者术后C5神经根麻痹的发生率为神经根麻痹的发生率为 1.4%，这也进一步支持预防性椎间孔切开有助于预防这也进一步支持预防性椎间孔切开有助于预防 C5 神经根麻痹。神经根麻痹。v 总的来讲，颈后路减压术后

15、总的来讲，颈后路减压术后 C5 神经根麻痹的平均发生率为神经根麻痹的平均发生率为 7.8%。Resultsv Cervical spondylotic myelopathy:We found that laminoplasty was the most commonly studied procedure for the treatment of this condition and the primary focus of many papers which addressed this problem were the use of different techniques to help

16、 avert a C5 nerve root palsy.v 脊髓型颈椎病：椎板成形术是治疗脊髓型颈椎病最常用的脊髓型颈椎病：椎板成形术是治疗脊髓型颈椎病最常用的方法方法,而且许多研究的主要目的是如何避免术后而且许多研究的主要目的是如何避免术后 C5 神经神经根麻痹。根麻痹。Resultsv While not reaching statistical significance, the wide-door group had an incidence of C5 palsy of 5.3% while the narrow-door group had an instance of 0%.v

17、 Due to the fact that a narrow open door decreasesv the potential space for movement of the spinal cord, these authors, as well as others, support the concept that a narrow door decreases the amount of posterior shift of the thecal sac.v 然而，虽然没有达到统计学意义，开门较宽组然而，虽然没有达到统计学意义，开门较宽组 C5 神经根麻痹的发生神经根麻痹的发生率为

18、率为 5.3%，开门较窄组的发生率则为，开门较窄组的发生率则为 0%。事实上，由于窄开门。事实上，由于窄开门可以减少脊髓漂移的空间，多数学者认为该方法可以有效降低硬膜囊可以减少脊髓漂移的空间，多数学者认为该方法可以有效降低硬膜囊受牵连的程度。受牵连的程度。Resultsv Ossification of the posterior longitudinal ligament (OPLL):These authors supported the tethering theory and state that laminectomy,in particular, allows posterior

19、shift of the cord at C5 because of over-restoration of the cervical lordosis by surgical instrumentation.v 颈椎后纵韧带骨化症颈椎后纵韧带骨化症OPLL：这些作者认为栓系理论（脊：这些作者认为栓系理论（脊髓向后漂移导致的神经根栓系）是该并发症发生的重要原髓向后漂移导致的神经根栓系）是该并发症发生的重要原因，同时他们认为，因，同时他们认为，内固定内固定重建使得颈椎重建使得颈椎前前曲过度恢复，曲过度恢复，进而造成进而造成 C5 水平脊髓向后漂移。水平脊髓向后漂移。Resultsv The po

20、sterior hybrid technique, in which laminoplasty is performed with lateral mass screw fixation, is an alternative technique to simple laminoplasty but still has the potential to cause a C5 root palsy. Two studies44,51 considered patients with OPLL and concurrent segmental instability. After surgical

21、decompression, their neurological symptoms had improved and their Japanese Orthopaedic Association (JOA) scores were better in the long term than in those who had only undergone laminoplasty. Despite this, the overall rate of C5 root palsy was similar in both groups and the authors.v 椎板成形及侧块螺钉固定等后路组

22、合式技术是椎板成形术之外的治疗椎板成形及侧块螺钉固定等后路组合式技术是椎板成形术之外的治疗选择，有研究认为选择，有研究认为 OPLL 患者同时存在颈椎节段不稳，减压术后患患者同时存在颈椎节段不稳，减压术后患 者神经功能改善，与仅行椎板成形术者相比，其远期者神经功能改善，与仅行椎板成形术者相比，其远期 JOA 评分更好。评分更好。尽管如此，两组患者总体尽管如此，两组患者总体 C5 神经根麻痹的发生率相近。因此，作者神经根麻痹的发生率相近。因此，作者也认为，混合式手术技术在预防也认为，混合式手术技术在预防 C5 神经根麻痹方面并无明确的优势。神经根麻痹方面并无明确的优势。Resultsv Prev

23、ention:Early detection of a C5 root palsy using neurophysiological monitoring can potentially avert post-operative neurological deficits.v 预防：应用神经电生理监测早期发现预防：应用神经电生理监测早期发现 C5 神经根麻痹能够神经根麻痹能够避免术后神经功能损伤。避免术后神经功能损伤。DiscussionvIt is difficult to interpret the 7.7% mean incidence of C5 palsy after anterio

24、r decompression when compared with that of 7.8% after posterior decompression.v相对于经后路减压术后相对于经后路减压术后 7.8% 的的 C5 神经根麻神经根麻痹发生率，很难解释颈前路减压术后的平均发生痹发生率，很难解释颈前路减压术后的平均发生率为率为 7.7%。Discussionv The origin of post-operative C5 palsy is likely to be multifactorial; however, posterior movement of the thecal sac c

25、ausing traction on the nerve root proved to be the most common postulated theory in our search.Anterior and posterior decompression are both believed to.Conclusionv 虽然关于术后虽然关于术后 C5 神经根麻痹的发生是多因素的，但是我神经根麻痹的发生是多因素的，但是我们的研究表明，减压术后硬膜囊的向后漂移对神经根的牵们的研究表明，减压术后硬膜囊的向后漂移对神经根的牵拉（栓系效应）是目前最常见拉（栓系效应）是目前最常见 / 流行的假设理论，而且流行的假设理论，而且无论前路还是后路手术均会引起硬膜囊的向后漂移。无论前路还是后路手术均会引起硬膜囊的向后漂移。Conclusionv Early detection and pre